Public Access Defibrillation Programs: Improving Outcomes Worldwide.

O ut of hospital cardiac arrest (OHCA) is one of the most frequent causes of death and leading cause of healthcare expenditures. This has led to significant research to study ways to reduce morbidity and mortality secondary to OHCA. The American Heart Association has developed a campaign to improve awareness and outcomes of patients suffering an OHCA. A prominent part of this campaign is the development of the chain of survival. The chain of survival includes 5 links: (1) Immediate recognition of cardiac arrest and activation of the emergency response system, (2) Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, (3) Rapid defibrillation, (4) Effective advanced life support, and (5) Integrated post-cardiac arrest care (http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/CPRFactsAndStats/UCM_475731_CPR-Chain-ofSurvival.jsp). For patients with an OHCA secondary to a ventricular arrhythmia, rapid defibrillation is a key factor to improved survival with minimal neurological impact. Studies show that rapid defibrillation within 5 minutes of a cardiac arrest secondary to ventricular fibrillation is needed to ensure a good outcome. A prospective randomized study showed that public access defibrillation (PAD) could increase the number of survivors with OHCA in public locations. In order to provide rapid access to defibrillation, PAD programs have been established to provide access to defibrillators in highuse public areas. Studies show that PAD programs in railways, casinos, and airports in the United States, Europe, and Japan have improved survival in patients with OHCA. Despite this, a study showed that PAD was deployed successfully in less than 2% of OHCA, suggesting that there are still areas that can improve their access and deployment of PAD. All of the studies of PAD programs have been in the United States, Europe, and Japan. No targeted PAD program had been studied in Latin America. In this issue of the Journal of the American Heart Association (JAHA), Gianotto-Oliveira et al look at survival after ventricular fibrillation cardiac arrest in the Sao Paulo Metropolitan Subway System following the implementation of a targeted PAD program. Their 2006 study was the first of a targeted PAD program in Latin America. The program placed automated external defibrillators in railway stations and provided Heartsaver First Aid cardiopulmonary resuscitation (CPR) automated external defibrillator training and refresher courses for security officers. The Sao Paulo railway system is an ideal location for a PAD program because the railway system carries approximately 4.5 million passengers per day. The systems-dedicated security officers and cameras allow for rapid recognition, CPR, and defibrillation. During the study period, 62 subjects had a cardiac arrest with an initial rhythm of ventricular fibrillation. Of the 62 subjects, 23 (37%) survived to hospital discharge with minimal neurological impairment. Survivors were younger and had shorter times from cardiac arrest to CPR, to the arrival of an automated external defibrillator, to the first defibrillator shock, and to the arrival of emergency medical services personnel. On multivariable analysis, time interval from collapse and first shock was the only variable associated with improved survival with minimal neurological compromise. When comparing the initial year of implementation of the PAD program with the last 5 years of the study, once full implementation had occurred, survival increased. Their study highlighted areas in need of improvement and showed that it is necessary to strengthen all parts of the chain of survival to achieve the ultimate goal. It was surprising to learn that during the 6-year study, no layperson performed CPR for any of the cardiac arrests. The first 2 links of the chain can be improved upon by increasing the number of laypersons who are willing and able to provide CPR when needed. We should seize the opportunity to continue to educate the public on the importance of CPR and identify The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX. Correspondence to: Santiago O. Valdes, MD, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX 77030. E-mail: [email protected] J Am Heart Assoc. 2015;4:e002631 doi: 10.1161/JAHA.115.002631. a 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.